High Seroprevalence of IgG Antibodies to Multiple Arboviruses in People Living with HIV (PLWHIV) in Madagascar

To estimate the prevalence of IgG antibodies against six arboviruses in people living with HIV-1 (PLWHIV) in Madagascar, we tested samples collected between January 2018 and June 2021. We used a Luminex-based serological assay to detect IgG antibodies against antigens from Dengue virus serotypes 1-4 (DENV1-4), Zika virus (ZIKV), West Nile virus (WNV), Usutu virus (USUV), Chikungunya virus (CHIKV), and O'nyong nyong virus (ONNV). Of the 1036 samples tested, IgG antibody prevalence was highest for ONNV (28.4%), CHIKV (26.7%), WNV-NS1 (27.1%), DENV1 (12.4%), USUV (9.9%), and DENV3 (8.9%). ZIKV (4.9%), DENV2 (4.6%), WNV-D3 (5.1%), and DENV4 (1.4%) were lower. These rates varied by province of origin, with the highest rates observed in Toamasina, on the eastern coast (50.5% and 56.8%, for CHIKV and ONNV, respectively). The seroprevalence increased with age for DENV1 and 3 (p = 0.006 and 0.038, respectively) and WNV DIII (p = 0.041). The prevalence of IgG antibodies against any given arborvirus varied over the year and significantly correlated with rainfalls in the different areas (r = 0.61, p = 0.036). Finally, we found a significant correlation between the seroprevalence of antibodies against CHIKV and ONNV and the HIV-1 RNA plasma viral load. Thus, PLWHIV in Madagascar are highly exposed to various arboviruses. Further studies are needed to explain some of our findings.

Prevalence, Risk Factors, and Genetic Characterization of Extended-Spectrum Beta-Lactamase Escherichia coli Isolated From Healthy Pregnant Women in Madagascar

Antimicrobial resistance is a major public health concern worldwide affecting humans, animals and the environment. However, data is lacking especially in developing countries. Thus, the World Health Organization developed a One-Health surveillance project called Tricycle focusing on the prevalence of ESBL-producing Escherichia coli in humans, animals, and the environment. Here we present the first results of the human community component of Tricycle in Madagascar. From July 2018 to April 2019, rectal swabs from 492 pregnant women from Antananarivo, Mahajanga, Ambatondrazaka, and Toamasina were tested for ESBL-E. coli carriage. Demographic, sociological and environmental risk factors were investigated, and E. coli isolates were characterized (antibiotic susceptibility, resistance and virulence genes, plasmids, and genomic diversity). ESBL-E. coli prevalence carriage in pregnant women was 34% varying from 12% (Toamasina) to 65% (Ambatondrazaka). The main risk factor associated with ESBL-E. coli carriage was the rainy season (OR = 2.9, 95% CI 1.3-5.6, p = 0.009). Whole genome sequencing was performed on 168 isolates from 144 participants. bla CTX-M-15 was the most frequent ESBL gene (86%). One isolate was resistant to carbapenems and carried the bla NDM-5 gene. Most isolates belonged to commensalism associated phylogenetic groups A, B1, and C (90%) and marginally to extra-intestinal virulence associated phylogenetic groups B2, D and F (10%). Multi locus sequence typing showed 67 different sequence types gathered in 17 clonal complexes (STc), the most frequent being STc10/phylogroup A (35%), followed distantly by the emerging STc155/phylogroup B1 (7%), STc38/phylogroup D (4%) and STc131/phylogroup B2 (3%). While a wide diversity of clones has been observed, SNP analysis revealed several genetically close isolates (n = 34/168) which suggests human-to-human transmissions. IncY plasmids were found with an unusual prevalence (23%), all carrying a bla CTX-M-15. Most of them (85%) showed substantial homology (≥85%) suggesting a dissemination of IncY ESBL plasmids in Madagascar. This large-scale study reveals a high prevalence of ESBL-E. coli among pregnant women in four cities in Madagascar associated with warmth and rainfall. It shows the great diversity of E. coli disseminating throughout the country but also transmission of specific clones and spread of plasmids. This highlights the urgent need of public-health interventions to control antibiotic resistance in the country.

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

BACKGROUND

80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality.

METHODS

This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494.

FINDINGS

Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70-8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39-8·80) and upper-middle-income countries (2·06, 1·11-3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26-11·59) and upper-middle-income countries (3·89, 2·08-7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications.

INTERPRETATION

Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications.

FUNDING

National Institute for Health Research Global Health Research Unit.

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

BACKGROUND

Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world.

METHODS

This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231.

FINDINGS

Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p<0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05-2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p<0·001).

INTERPRETATION

Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication.

FUNDING

DFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant, National Institute of Health Research Global Health Research Unit Grant.

Joint pain epidemiology and analgesic usage in Madagascar

Introduction

To describe the epidemiology of joint pains and document analgesics usage in an African context.

Methods

Patients suffering from joint pain were recruited from nine sites located in Antananarivo, Madagascar, including 6 hospital services and 3 clinics. Doctors collected information on the etiology and characteristics of the patients’ pain. Analgesics prescribed by these doctors were also documented.

Results

In total, 400 patients were enrolled in the study (52.5% women, mean age of 42.34 years ± 17.7 [4-86]). Pain of mechanical type was found in 260 participants, 65%; 95% CI [60.1% to 69.6%] and inflammatory type pains in 128 cases 32%; 95% CI [27.5% to 36.9%]. Mixed pains were found in 12 patients (3%). The median duration of pain prior to the consultation was 6.5 days. The average pain intensity was 57.9 ± 19.9 mm of a total of 100 mm maximum on a visual analogue scale, VAS. The etiologies of mechanical type pains were dominated by fracture, common low back pain and tendonitis. Arthrosis was the dominant cause of inflammatory type pain, followed by rheumatoid arthritis and gout. NSAIDs (74.5%) were the most frequently prescribed analgesics followed by paracetamol (49.5%), weak opioids (23%) and corticosteroids (12.25%). Two-thirds of medical prescriptions (65.3%) were of combined analgesics.

Conclusion

These findings demonstrated that mechanical type pains were the main reason for consultations for joint pain in these situations in Antananarivo, Madagascar. The most frequently prescribed pain-relieving medications were NSAIDs, paracetamol, weak opioids and corticosteroids. This descriptive study may be a useful starting point for further epidemiological studies of pain in the African context.

[Pseudosyndrome of Meigs revealer of an ovarian goiter]

The pseudosyndrome of Meigs is caracterised by a triad, which associates a solid benign tumor of the ovary, an ascitis and a pleural effusion. Surgical extraction of the tumor entails disappearance of the symptomatology. The authors report in this study a case of an ovarian goitre revealed by this syndrom.

[Gastrointestinal stromal tumor of the ileum with metastatic relapse developed in the mesentery]

Nous rapportons le cas d'un homme de 29 ans admis pour une masse hypogastrique très douloureuse. La laparotomie exploratrice réalisée en urgence permettait de mettre en évidence l'origine et la localisation iléale de la masse tumorale. Le traitement chirurgical consistait en une tumorectomie complète avec respect des marges carcinologiques. Les suites opératoires étaient simples et l'examen histologique confirmait la nature stromale de la tumeur iléale réséquée. Les marges de résection passaient en tissus sains. Le patient était perdu de vue et n'ayant reçu aucun traitement adjuvant. Un an plus tard, il est revenu pour ballonnement et masse pelviens d’évolution rapidement progressive et dont l'exploration chirurgicale révélait l'existence d'une tumeur mésentérique. Une tumorectomie était réalisée mais incomplète à cause d'une perte sanguine avec instabilité hémodynamique induite par l'exérèse tumorale. Après analyse histologique et immunohistochimique de la pièce opératoire, le diagnostic d'une tumeur stromale était confirmé. Il s'agissait d'une rechute métastatique à localisation mésentérique d'une tumeur stromale digestive d'origine iléale à fort potentiel malin. La réduction tumorale suivie d'un complément thérapeutique par l'Imatinib (glivec^®) permettaient d'obtenir un résultat satisfaisant. Avec un recul de 12 mois, le patient était asymptomatique et aucune récidive locale ni de métastase à distance n'a été observée.

First results of hormone receptors' status in Malagasy women with invasive breast cancer

INTRODUCTION

Breast cancer is the most common malignancy tumor amongst Malagasy women registered at the pathology unit of the "Institut Pasteur de Madagascar". In Madagascar, there is no laboratory practicing hormone receptors' status on these tumors. Until now no study about hormone receptors' status of Malagasy women with invasive breast cancer was performed. So it will be the first study talking about this topic. The aim of this study was to determine hormone receptors' status in Malagasy women with invasive breast cancer.

METHODS

This retrospective and descriptive study was based on patients' medical files from 2009 to 2011. It included all invasive breast cancer diagnosed in Malagasy women at the pathology laboratory located at the "Institut Pasteur de Madagascar", in Antananarivo. Along this period this laboratory has sent paraffin blocks of invasive breast carcinoma in two pathological laboratories in France.

RESULTS

We collected 77 cases of invasive breast cancer along this period. The mean age was 48.8 +/- 10.7, ranging from 26 years to 70 years. There were 46.8 % (n = 36) women with progesterone receptor positive (PR+), 53.2 % (n = 41) with progesterone receptor negative (PR-). For the estrogen receptor, 61.0 % (n = 47) were positive and 36.4 % (n = 28) were negative. ER+/PR+ represented 44.2 % (n = 34); ER-/PR- 33.8 % (n = 26); ER +/ PR- 16.8 % (n = 13); ER-/PR+ and ER-/PR- represented respectively 2.6 % (n = 2).

CONCLUSION

Patients in our study had more important rate of ER-, PR- and a less important rate of ER+/PR+, PR+. These results suggest that more study related to Hormone Receptor profile should be conducted in Malagasy women with breast cancer.

[Necrotizing fasciitis of the chest wall complicating an empyema]

La fasciite nécrosante est une infection sévère, rapidement progressive, mutilante, souvent fatale du tissu sous cutané et du fascia profond. Les auteurs rapportent et discutent un rare cas de fasciite nécrosante de la paroi thoracique antérieure secondaire à une pleurésie purulente chez un diabétique. Un diagnostic précoce avec incisions multiples chirurgicales et une antibiothérapie adaptée par voie veineuse diminuent la morbidité et la mortalité causées par cette pathologie.

[Result of surgical treatment of pulmonary aspergillosis secondary to a sequelae of tuberculosis in CHU/JRA]

La prise en charge d’un aspergillome pulmonaire, dans le cas des lésions limitées accessibles, est une des activités courantes en chirurgie thoracique dans les pays endémique à la tuberculose comme Madagascar. Sur une période allant de janvier 2005 en mars 2010, 15 patients, ancien tuberculeux, atteints d’une aspergillome pulmonaire sont traités par une résection segmentaire ou une lobectomie. La circonstance de découverte repose sur la clinique par des tableaux très polymorphes. L’imagerie garde une place importante. L’examen histologique des pièces d’exérèse chirurgicale confirme le diagnostic. Tous les patients ont été opérés de manière élective. Le résultat a été pour l’ensemble des patients jugés satisfaisant. Ces patients sont suivis pendant 1 à 39 mois. L’étude des résultats à distance est encore en cours et est fondamentale si le traitement chirurgical a un effet bénéfique sur la survie et la qualité de vie des malades. Le but de ce travail a été, à partir de la revue de la littérature et de notre petite expérience, de définir quels éléments pertinents mis en exergue sur le sujet.

Comparaison de deux scores pronostiques dans les hémorragies digestives hautes non variqueuses dans un centre hospitalier d’Antananarivo

Il est actuellement recommandé de stratifier les hémorragies digestives hautes, en fonction de leur risque, par des scores pronostiques. L'objectif de cette étude a été d'appliquer ces scores en vue de les comparer, dans un centre hospitalier malgache. Etude prospective sur 419 patients, sur une période entre janvier et décembre 2011, au Centre Hospitalo-Universitaire d'Antananarivo. Les scores de Rockall initial et de Blatchford ont été calculés pour chaque patient présentant une hémorragie digestive haute non variqueuse dont les dossiers été complets, avec notamment la valeur de l'urémie et de l'hémoglobine. Une comparaison de ces deux scores a été faite pour déterminer le pronostic et l’évolution de cette pathologie. 46,3% des dossiers n'avaient pas de valeur d'urémie ni de l'hémoglobine. Les 185 patients retenus, avaient une moyenne d’âge de 48,2 ± 18,2 ans et une prédominance masculine (72,4%). Le risque clinique était élevé dans 62,7% des cas, dont 59,4% ont bénéficié d'une transfusion. Une mortalité de 9,7% a été observée. Le score de Blatchford était plus prédictif du risque clinique par rapport au score de Rockall initial (AUROC = 0,82 vs 0,64; p < 0,0001), mais aussi de la nécessité d'une transfusion (AUROC = 0,79 vs 0,62; p= 0,00013). L'instauration d'un score clinico-biologique est assez limitée par faute de moyens, alors que le score de Blatchford aiderait en matière de pronostic des hémorragies digestives hautes.

[Traumatic complete isthmic rupture of horseshoe kidney]

The authors report the case of a 14-year-old boy with complete isthmic rupture of a horseshoe kidney after a bicycle accident. The imaging diagnosis was difficult because of the presence of a massive retroperitoneal haematoma. However, sonography and CT should be sufficient to detect associated signs, such as malrotation of the renal hila and low-lying kidneys. Laparotomy was indicated because of the unstable haemodynamic state, allowing haemostasis and suture of the two isthmic sections.

[Two cases of breast tuberculosis in Madagascar]

Breast tuberculosis is rare. It usually involves young women of childbearing age. The purpose of this report is to describe two cases of breast tuberculosis observed in Madagascar with focus on epidemiological, clinical, and therapeutic features. Infection of the breast is usually secondary by lymphatic, contiguous, or, more rarely haematogenous spreading. Primary infection is uncommon. The most frequent clinical form is the fistulised nodular form observed in both patients described in this report. The diffuse form is the least common form and the sclerous form occurs in the elderly. Histology is a valuable diagnostic tool if bacteriological findings are inconclusive. Patients respond favourably to antimycobacterium treatment with or without surgery.

[Bartholin gland tuberculosis: a case report in Madagascar]

Female genital tuberculosis is relatively frequent in developing countries. Most cases occur in young women of childbearing age. The most common locations are the tubes, endometrium, and ovaries. Bartholin gland involvement is rare. The purpose of this report is to present a case of Bartholin gland tuberculosis in a 50 year-old woman and to describe the special epidemiological, clinical and therapeutic features associated with this location. Bartholinitis develops insidiously until spontaneous fistula formation. The lesion then gradually assumes a vegetative appearance that persists despite antibiotic treatment. Diagnosis requires biopsy findings demonstrating the presence of granulomatous tissue with caseous necrosis. Patients respond favorably to specific medical treatment. The recent spread of human immunodeficiency virus has increased the need to continue and improve efforts to control turberculosis particularly in endemic zones.

[Giant bladder calculus in two male farmers in Madagascar]

We report two cases of giant calculus in two male farmers in 1999. They were operated on in the urologic ward by lithocystotomy. Infrared spectrophotometric analysis, carried out in Bordeaux, gave us the main components of the stones. These stones weighed respectively 350 g and 450 g. Research of common aetiology such as vesical neck stricture, prostatic hypertrophy, urethral stricture and urinary bladder diverticula was unsuccessful in case of the first patient; in the opposite, the second one had vesical diverticula discovered operatively. But two phenomena came out from this aetiologic investigation: particular regimen of these farmers (much starchy food) and geographical situation of their health centre (far from their home). We must make general practitioners sensitive to this early signs of the disease in order to provide their patients a precocious and better care.